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Declaration

This work is original and has not been submitted previously in support of a degree

qualification or other course.

. ..

Signed Date

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Abstract

Introduction: Coronary heart disease (CHD), a gradual build up of fatty deposits in the

coronary arteries, occurs as a result of several risk factors (RFs) with 75% attributable to

lifestyle choices. Accordingly, CHD prevention focuses on the three lifestyle RFs; smoking,

physical activity/exercise and diet/weight management. As CHD prevention is a complex process, it adopts social cognition theories that have established knowledge as an essential

component for behaviour change. Despite the widespread acceptance of CHD prevention,

CHD still kills more people than any other disease accounting for 7.2 million global deaths

per year and thus, there is an obvious need for prevention development. Student nurses,

potential advocate for such initiatives, could effectively help make an impact on CHD

through the use of health education/promotion but research has determined substantial

knowledge gaps and that nurses do not practice what they preach. Aim(s): To evaluate CHDknowledge and the health behaviour (HB) of student nurses by identifying whether they have

sufficient knowledge, whether they practice HBs, whether there is a relationship between the

student nurses CHD knowledge and HB and whether the age or gender of the student nurse

affects CHD knowledge and HB. Methods: Third year student nurses from Universities in

the north of England were asked to complete an online CHD Knowledge and Health

Behaviour Questionnaire (CHDKHBQ). CHD knowledge and HB scores were generated (0-

16 and 10-29, respectively) and subsequently categorised as poor, average and good. Results:

54 third year student nurses from five Universities took part in the study. The CHD

knowledge of the third year student nurses was classified as good (mean = 13) and the HB of

the third year student nurses was found to be average (mean = 19). There was no significant

relationship (p=0.44) between the student nurses CHD knowledge and HB reported. No age-

related differences were established between third year student nurses straight from school

education and mature students and their CHD knowledge (p=0.21) and HB (p=0.71). No

CHD knowledge and gender differences occurred (p=0.51) but there was significant gender

differences in relation to HB (p=0.04). Conclusion: Third year student nurses do possess a

sufficient level of CHD knowledge to provide health education/promotion through CHD

prevention however, do not fully practice these HBs and thus there is a requirement to

development promoting HBs in nurses. This would ultimately benefit heath

education/promotion as it is unlikely that individuals would take advice if the person

delivering crucial CHD information contradicts this through there own behaviour. Knowing

that there are gender specific differences also identifies that health education/promotion may

need to develop as gender specific.

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Contents Page No.

Chapter One: Introduction 1 - 9

1.1. Coronary Heart Disease 2

1.2. Risk Factors 2

1.2.1. Major Risk Factors 3

1.2.2. Contributing Risk Factors 4

1.3. Risk Factor Modification 5

1.4. Coronary Heart Disease Prevention 6

1.5. Coronary Heart Disease Prevalence 7

1.6. Rationale of Study 8

Chapter Two: Literature Review 10 - 30

2.1. Introduction to the Literature Review 11

2.2. Defining Coronary Heart Disease Knowledge and Health Behaviour 11

2.3. Social Cognition Models for Health Behaviour The Association

between Knowledge and Behaviour 12

2.4. Coronary Heart Disease Knowledge in the General Population 14

2.5. Coronary Heart Disease Knowledge in Patients 17

2.6. Coronary Heart Disease Knowledge in Health Professionals 20

2.7. Coronary Heart Disease Knowledge in Students 23

2.8. Age-related Differences in Coronary Heart Disease Knowledge 25

2.9. Gender Differences in Coronary Heart Disease Knowledge 27

2.10. Aim(s) 29

2.11. Hypotheses 29

2.11.1. Experimental Hypotheses 29

2.11.2. Null Hypotheses 30

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Page No.

Chapter Three: Methodology 31 - 38

3.1. Introduction to Methodology 32

3.2. Participants 32

3.3. Data Collection Tool 33

3.4. Data Collection Procedure 35

3.5. Data Analysis 36

Chapter Four: Results 39 - 58

4.1. Introduction to Results 40

4.2. Demographics 40

4.3. Coronary Heart Disease Knowledge 42

4.4. Health Behaviour 44

4.5. The Association between Coronary Heart Disease Knowledge

and Health Behaviour 49

4.5.1. Smoking 49

4.5.2. Physical Activity/Exercise 50

4.5.3. Diet/Weight Management 51

4.3. Age-related Differences in Coronary Heart Disease Knowledge

and Health Behaviour 55

4.4. Gender Differences in Coronary Heart Disease Knowledge

and Health Behaviour 56

Chapter Five: Discussion 59 - 71

5.1. Introduction to Discussion 60

5.2. Coronary Heart Disease Knowledge 60

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Page No.

5.3. Health Behaviour 64

5.4. The Association between Coronary Heart Disease Knowledge

and Health Behaviour 67

5.5. Age-related Differences in Coronary Heart Disease Knowledge

and Health Behaviour 69

5.6. Gender Differences in Coronary Heart Disease Knowledge

and Health Behaviour 70

Chapter Six: Conclusion 72 - 75

6.1. Conclusion 73

6.2. Limitations and Recommendations 74

Chapter Seven: References 76 - 96

Chapter Eight: Appendices 97 - 141

1. Specimen Email to University 98

2. University Confirmation Emails 99 - 103

a. University of Bradford 99

b. University of Huddersfield 100

c. Liverpool University 101

d. Manchester Metropolitan University 102

e. Northumbria University 103

3. Sample Size Summary 104

4. Review of Methodology 105

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Page No.

5. Coronary Heart Disease Knowledge and Health Behaviour

Questionnaire (CHDKHBQ) 123

6. Justification for Question Selection 127

7. Questionnaire Scoring Sheet 130

8. Confirmation Letter for Ethical Approval 133

9. Specimen Email to Students 134

10. Specimen of Questionnaire in Survey Monkey 135

11. Participant Information Sheet 137

12. Specimen Follow-up Email to University 138

13. SPSS Output Tests of Normality and Homogeneity of Variance 139

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List of Tables Page No.

Table 1 Coronary Heart Disease Major Modifiable Risk Factors 3

Table 2 CHDKHBQ Scoring Categories 35

Table 3 Summary of Coronary Heart Disease Knowledge Questions 43

Table 4 Smoking Knowledge vs. Smoking Behaviour 50

Table 5 Physical Activity/Exercise Knowledge vs. Physical Activity/

Exercise Behaviour 51

Table 6 Salt Knowledge vs. Salk Intake 52

Table 7 Fish Knowledge vs. Fish Consumption 52

Table 8 Fruit and Vegetable Knowledge vs. Fruit and Vegetable Intake 52

Table 9 Alcohol Knowledge vs. Alcohol Consumption 53

Table 10 Fat Knowledge vs. Spread and Oil Use 54

Table 11 Fat Knowledge vs. In-between Meal Snack Score 55

Table 12 Coronary Heart Disease Knowledge and Health Behaviour

Scores by Age 55

Table 13 - Coronary Heart Disease Knowledge and Health Behaviour

Scores by Gender 56

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List of Figures Page No.

Figure 1 The Process of Atherosclerosis 2

Figure 2 The Global Prevalence of Coronary Heart Disease in 2004 7

Figure 3 The North of England 33

Figure 4 Calculations for Health Behaviour Cut-Off Percentages 35

Figure 5 Distribution of Student Nurses between the Five Different

Universities 40

Figure 6 The Student Nurses by Age 41

Figure 7 The Student Nurses by Gender 41

Figure 8 The Branch of Nursing Studied by the Student Nurses 42

Figure 9 Smoking Behaviour of the Student Nurses 44

Figure 10 Physical Activity/Exercise Behaviour of the Student Nurses 45

Figure 11 Salt Intake of the Student Nurses 45

Figure 12 Weekly Fish Consumption of the Student Nurses 46

Figure 13 Daily Fruit and Vegetable Intake of the Student Nurses 46

Figure 14 Alcohol Consumption of the Student Nurses 47

Figure 15 Spread Use of the Student Nurses 47

Figure 16 Oil Use of the Student Nurses 48

Figure 17 Snack Score for the In-between Meal Snacks Consumed by the

Student Nurses 48

Figure 18 The Relationship between Coronary Heart Disease Knowledge

and Health Behaviour in Student Nurses 49

Figure 19 Amount of Correct Answers Provided For Question 8 by Gender 57

Figure 20 Smoking Behaviour of the Male Student Nurses 57

Figure 21 Fish Consumption of the Male Student Nurses 58

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List of Abbreviations

BP Blood Pressure

CHD Coronary Heart Disease

CHDKHBQ Coronary Heart Disease Knowledge and Health Behaviour Questionnaire

HB(s) Health Behaviour(s)

RF(s) Risk Factor(s)

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1.1. Coronary Heart Disease

Coronary heart disease (CHD) is caused by the process of atherosclerosis (American

Association for Cardiovascular and Pulmonary Rehabilitation [AACVPR], 2006), a gradual

build up of fatty deposits in the walls of the coronary arteries (British Heart Foundation

[BHF], 2010). Initially formed as a result of damage to the inner lining of the artery

(endothelium), these fatty deposits; known as plaques, cause the artery to narrow and obstruct

the flow of blood to the heart (Mullany, 2003). Over time, the artery may become so narrow

that blood supply to the heart is insufficient and can lead to angina (BHF, 2010).

Furthermore, if a fragment of the plaque breaks away from the endothelium it can result in

the formation of a clot, which blocks the artery and starves the heart of blood and oxygen

(BHF, 2010). This is known as a myocardial infarction (MI) (BHF, 2010). Figure 1 illustrates

this process.

Figure 1 - The Process of Atherosclerosis

1.2. Risk Factors

Extensive clinical and statistical studies have acknowledged several factors that

increase the risk of developing CHD (American Heart Association [AHA], 2010). While each

factor is important independently, the risk of developing CHD is also strongly related to a

combination of factors and it appears that the effect is synergistic (Scottish Public Health

Observatory, 2010). CHD risk factors (RFs) can be either classified as major RFs; those that

have shown to significantly increase CHD, or contributing RFs; those only associated with

CHD and have yet to be precisely determined (AHA, 2010).

Normal cross-section of artery

Tear inendothelium

Plaques depositnarrowing

artery

Narrowed artery becomes

blocked by clot

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1.2.1. Major Risk Factors

Major RFs include both modifiable and non-modifiable RFs. Modifiable RFs are

those that can be changed, controlled or treated by changing lifestyle habits or taking

medication (AHA, 2010). Table 1 details the modifiable RFs as well as describing how each

factor increases CHD development.

Table 1 Coronary Heart Disease Major Modifiable Risk Factors

Risk Factors How does the risk factor increase CHD development?

TobaccoSmoke

Causes impairment to endothelial function for plaque formation, induces an

inflammatory response to promote plaque rupture and increases the clotting property

of blood (Ambrose and Barua, 2004). Tobacco smoke also reduces the amount of

oxygen the blood is able to carry (Cutting, 2004) and thus increases blood pressure

(BP) (AHA, 2010).

High BP

(also termed

Hypertension)

Increases the heart's workload (AHA, 2010). Over time this can induce extraordinary

wear and tear on endothelial function, contributing to plaque formation (Escobar,

2002). The increased pressure exerted within the vessels can also exacerbate the

atherosclerotic process; due to the prolonged exposure to circulating particles

(AACVPR, 2006), as well as making the atherosclerotic plaque more unstable

(Escobar, 2002).

High Blood

Cholesterol

Increases plaque formation and plaque progression in the arteries, given that the

process of atherosclerosis is dependant on the accumulation of cholesterol (AACVPR,

2006).

Physical

Inactivity

Although not an autonomous risk of CHD, being physically active helps prevent or

delay the onset of high BP, lowers blood cholesterol levels, helps to control weight,

increases physical fitness and helps to control blood glucose in persons with diabetes

mellitus (AHA, 2010).

Obesity and

Overweight

Increases the heart's work load and subsequently raises BP (AHA, 2010). Since obese

or overweight individuals typically have high fat diets there is also an association with

high blood cholesterol (AHA, 2010). Furthermore, being obese or overweight

increases the likeliness of developing diabetes mellitus (AHA, 2010).

Diabetes

Mellitus

High blood glucose levels in persons with diabetes mellitus damage blood vessels and

subsequently lead to the formation of plaques (National Institute of Health, 2005).

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Non-modifiable RFs are unchangeable and consist of increasing age, male gender and

heredity (AHA, 2010). Largely based on the assumption that a cumulative measure of a

lifetime of coronary risk increases the likeliness of atherosclerosis (Vliegenthart et al. 2005),

older individuals (65+ years) are more likely to have CHD and die as a result (AHA, 2010).

Males have a greater risk of CHD compared to females and are also more likely to have

coronary events earlier in life (AHA, 2010). This is due to the fact that the female hormone

oestrogen provides a consistent protective effect against CHD, through its association with

lipid metabolism (Williams, 1997). Once past the menopause however, a womans risk

becomes similar to a mans (Mackay & Mensah, 2004).

Children of parents with CHD are also more likely to develop the disease themselves

as they typically present with one or more of the same RFs (AHA, 2010). The occurrence of a

coronary event in a first-degree blood relative before the age of 55 years (in a male relative)

or 65 years (in a female relative) can additionally, increase the risk of developing CHD

(Mackay et al. 2004). African Americans have more severe high BP than Caucasian

Americans and thus tend to have a higher risk of developing the disease (AHA, 2010). CHD

risk is also higher among Indians and other Asians, partly due to higher rates of obesity and

diabetes mellitus (AHA, 2010).

1.2.2. Contributing Risk Factors

Contributing RFs to CHD development comprise of stress and alcohol consumption

(AHA, 2010). Stress is thought to affect CHD through the direct and prolonged activation of

the autonomic system (Chandola, Britton, Brunner, Hemingway, Malik, Kumri et al. 2008).

This exposes the body to persistent elevated levels of stress hormones like adrenaline, which

accelerate the development of atherosclerosis (Johansson, Wickman, Skott, Gan & Berstrom,

2006). Johansson et al. (2006) suggests this persistent exposure to stress hormones can also

change the way blood clots, increasing the risk of an MI. Additionally, stress is said to

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contribute to high BP and often leads to neglect of a healthy lifestyle; such as poor eating

habits (Heart UK, 2004). This consequently increases such factors as obesity and overweight

and high blood cholesterol (Heart UK, 2004).

Alcohol consumption is also said to increase the risk of atherosclerosis directly and

may involve such processes as inflammation or cholesterol oxidation (Pletcher, Varosy,

Kiefe, Lewis, Sidney & Hulley, 2005). But it is thought that the likeliness of CHD is

increased through its association with such factors as obesity and overweight, high blood

cholesterol and diabetes mellitus (AHA, 2010); given its calorie content, and high BP as

alcohol is shown to increase the sheer stress and turbulent flow of blood (Pletcher et al.

2005).

1.3. Risk Factor Modification

Knowing that CHD development is caused by several RFs, prevention of CHD

concentrates on risk factor modification; reducing the extent of the RF or reducing the

number of RFs one presents with (AHA, 2010). As approximately 75% of RFs are

attributable to lifestyle choices (Mackay et al. 2004), risk factor modification focuses on three

main lifestyle RFs; smoking cessation, physical activity/exercise and diet/weight

management (British Association for Cardiac Rehabilitation [BACR], 2007). The BACR

(2007) state exercise and physical activity coupled with a healthy diet and avoidance of

obesity and smoking represents a lifestyle that is strongly associated with good

cardiovascular health, and a large body of evidence shows that modification of these can

significantly reduce the risk of CHD (Kannel & Wilson, 1995).

In order to achieve smoking cessation, make healthier food choices and become

physically active (Ford & Jones, 1991) however, requires an individual to give up or modify

a behaviour that is firmly established (Miller & Taylor, 1995) and thus promoting a healthy

lifestyle is a complex phenomenon (Sanderson, Waller, Jarvis, Humphries & Wardle, 2009).

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Risk factor modification consequently, adopts theories derived from social cognition models

of health behaviour (HB) which posit a range of factors that influence behaviour (Marteau &

Weinman, 2006). Since the basic factor for these cognitions is 'knowing the negative

consequence of the behaviour' (Parker & Assaf, 2005), knowledge of CHD is viewed as an

essential component in risk factor modification and in the prevention of CHD (Ford et al.

1991; Jafray, Aslam, Mahmud, Waheed, Shakir, Afzal et al. 2005).

1.4. Coronary Heart Disease Prevention

CHD prevention exists as primary or secondary prevention. Primary prevention

generally means the effort to modify or prevent the development of CHD RFs to delay or

prevent new-onset CHD (Grundy, Balady, Criqui, Fletcher, Greenland, Hiratzka et al. 1998).

Typically provided through the use of media; both electronic and print (Khan, Jafray, Jafar,

Faruqui, Rasool et al. 2006), primary prevention informs those at risk about CHD and its RFs

as well as trying to encourage a better lifestyle behaviour (Hardcastle, Taylor, Bailey &

Castle, 2008). Examples of primary prevention could be smoking cessation resources like the

Quit Kit or the Change 4 Life campaign which promotes better eating and more physical

activity.

The term secondary prevention denotes therapy to reduce recurrent coronary events

and decrease CHD mortality in patients with established CHD (Grundy et al. 1998). Its aim is

therefore, at both the control of RFs and the direct therapeutic protection of coronary arteries

from plaque eruption (Grundy et al. 1998). Since this population have been typically admitted

to hospital following a coronary event, first hand information about CHD is communicated

by health professionals (Khan et al. 2006). In addition, patients with CHD are enrolled onto

Cardiac Rehabilitation (CR), a scheme which aims to achieve and maintain optimal physical

and psychosocial health (Scottish Intercollegiate Guidelines Network [SIGN], 2003) through

exercise, education and psychological support (Dinnes, Kleijnen, Litner & Thompson, 1999).

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Informing patients about CHD, its RFs, the benefits to exercise and healthy eating, and

medication, could be examples of CR education.

Widespread acceptance of the benefits of CHD prevention initially came in secondary

prevention (Smith, Blair, Criqui, Fletcher, Fuster, Gersh et al. 1995), which has shown to

significantly reduce recurrent coronary events and CHD mortality rates (Taylor, Brown,

Ebrahim, Joliffe, Noorani, Rees et al. 2004). The United Kingdom (UK) alone has seen a

40% decline in CHD deaths (BHF, 2008). In doing so, health education has also been found

to be an effective prevention strategy (Taha, Al-Almai, Zubeir, Mian & Hussain, 2004) by

significantly improving a patients overall HB (Salamonson, Everett, Davidson & Andrew,

2007). Less is known about the effect of primary prevention, as it is difficult to adequately

estimate the incidence of people admitted to hospital with new-onset CHD (Mathur, 2002),

but the use of media messages have shown to significantly improve HB (Chew, Palmer,

Slonska & Subbiah, 2002).

1.5. Coronary Heart Disease Prevalence

Despite an improved survival rate with the introduction of CHD prevention, CHD still

kills more people than any other disease accounting for 7.2 million global deaths per year

(Mackay et al. 2004). Figure 2 illustrates the global prevalence (per 100,000) for CHD .

Figure 2 The Global Prevalence of Coronary Heart Disease in 2004Source: Mathers, Bernard, Iburg, Inoue, Ma Fat, Shibuya et al. (2008) Global Burden of Diseases: data sources,

methods and results, as cited in WHO (2010)

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In industrialised countries CHD is the most common cause of morbidity and mortality

(Sebregts, Falger & Bar, 2000). In the UK approximately 1.4 million suffer from angina,

annually around 3 million suffer an MI (SIGN, 2003), and more than 103,000 die per year as

a result of CHD (National Institute for Health and Clinical Excellence [NICE], 2007). In the

US approximately every 26 seconds an American will experience an acute coronary event

and approximately every minute an American will die from one (AHA, 2004). This accounts

for over 400,000 deaths per year (AHA, 2010). CHD also takes the lives of 2 million

Europeans (Koutoubi, Huffman, Ciccazzo, Himburg & Johnson, 2005) and over 200,000

people in Australia (AHA, 2004), each year.

In developing countries, which were once seen less affected by the disease (Jafray et

al. 2005), CHD is also now high on the top 10 mortality list (Mackay et al. 2004). The AHA

(2004) reported that in 2004, over 700,000 people in China, over 140,000 people in Brazil,

nearly 1.5 million people in India and approximately 350,000 in all regions of Africa died as

a result of CHD. Largely attributable to western influences (Jafray et al. 2005) this is

particularly problematic as some developing populations face a double burden of risk,

grappling with the problems of under nutrition and communicable diseases (Mackay et al.

2004).

1.6. Rationale for Study

Evident that the prevalence of CHD is still high in most countries and also on the rise

globally (Khan et al. 2006); a true pandemic that respects no borders (Mackay et al. 2004),

there is an obvious need to develop current CHD prevention. This would include focusing on

the established findings that knowledge of CHD is essential for risk factor modification

(Crouch & Wilson, 2010).

Nurses play a key role in the prevention of CHD viewing their responsibility not only

as carers but as health educators (Steptoe, Doherty, Kendrick, Rink & Hilton, 1999). One

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might expect that, given the education background and hands on experience, nurses would

have a heightened awareness of CHD and consequently provide sufficient health

education/promotion to facilitate better HB. However, there seems to be evidence that

suggests substantial CHD knowledge gaps in nurses (Wilt, Hubbard & Thomas, 1990) and

thus it is important to determine if nurses are suitably equipped to provide such health

education\promotion.

Additionally, one would also expect nurses to adopt a healthier lifestyle (Undertaking

Nursing Intervention throughout Europe [UNITE], 2002), though a large body of evidence

suggests that nurses do not practice what they preach and demonstrate unhealthy behaviours

(Jaarsma, Stewart, De Geest, Fridlund, Heikkila, Martensson et al. 2004). Does the

knowledge to behaviour relationship therefore exist with regards to CHD prevention? Or

alternatively, are nurses good role models to provide health education/promotion, as there is

little doubt that people are unlikely to follow advice if the person delivering crucial

information about CHD appears to contradict this through their own lifestyle (Jaarsma et al.

2004).

Providing this evidence is being established for the future development of CHD

prevention, it is consequently important to determine CHD knowledge and HBs within the

future population of nurses that will provide such strategies, that is student nurses. Student

nurses could be potential advocates for CHD prevention and possibly effectively help make

an impact on the CHD prevalence that we see today.

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Chapter Two:

Literature Review

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2.1. Introduction to Literature Review

The purpose of this literature review is to identify and discuss those studies that relate

to CHD knowledge and its association with HB. To understand this association, the review

will initially consider the social cognition models for HB that have established knowledge as

a pre-requisite for behaviour change (Jafray et al. 2005). Given that knowledge is the basis

for behaviour change, the review will also examine CHD knowledge in different populations;

the general population, patients, health professionals and students, as well as providing

evidence for their HBs. Furthermore, as some studies have shown that demographic variables

such as age and gender have modified disease prevention behaviours (Chew, Palmer & Kim,

1998), this literature review will also identify any age-related or gender differences in CHD

knowledge and the subsequent effects on HB. This will put the present study into context,

establishing the aims and proposed hypotheses of the study.

2.2. Defining Coronary Heart Disease Knowledge and Health Behaviour

Prior to an extensive evaluation into CHD knowledge and HB research, it is firstly

important to consider and identify what CHD knowledge and HB entails. After reviewing a

vast array of literature it is clear that the following terminologies can be used as definitions

for both variables.

CHD Knowledge is an understanding, awareness, perception, or conception of the

general pathophysiology, RFs, symptoms, prevention and treatments associated with

CHD.

(Mosca, Jones, King, Ouyang, Redburg, Hill et al. 2000; MacInnes 2005; Byrne, Walsh

& Murphy, 2005; Lin, Furze, Spilsbury & Lewin, 2008; Kayaniyil, Arden, Winstanley,

Parsons, Brister, Oh et al. 2009; Ayres & Myers, 2010; Crouch et al. 2010).

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HB is recognised as an action taken by an individual to maintain, attain, or regain

good health, and to prevent illness. This includes stopping smoking, making healthy

food choices, becoming physically active, achieving an ideal weight, consuming

alcohol in moderation, achieving normal BP levels and achieving total cholesterol

levels within the recommended range

(Alm-Roijer, Stagmo, Uden & Erhardt, 2004; Koutoubi, Huffman, Ciccazzo, Himburg &

Johnson, 2005; Byrne et al. 2005; Ford et al 1991; Stampfer, Hu, Manson, Rimm &

Willet, 2000).

2.3. Social Cognition Models for Health Behaviour The Association between

Knowledge and Behaviour

Health psychology offers a number of models that seek to help us understand the

association between knowledge and behaviour (Byrne et al. 2005). Although there are

several, the most commonly used approach is the health belief model (Diefenbach &

Leventhal, 1996; Troein, Rastam & Selander, 1997). The health belief model is constructed

of five basic factors that influence disease prevention behaviours; perceived susceptibility,

which refers to a persons beliefs about the possibility of getting the disease; perceived

seriousness of the consequences of the disease, such as a disability or mortality; perceived

benefits of performing the recommended behaviour, like feeling healthier or living longer;

perceived barriers to the suggested actions, which may include cost or time; and finally, cues

to action, which may constitute a physicians advice, print or electronic advertisement (Chew

et al. 2002).

The health belief model states that the cumulative affect of an individuals readiness

to act (presence of perceived susceptibility and perceived seriousness) and efficacy of the

recommended response (perceived benefits outweigh perceived barriers) results in preventive

HB (Chew et al. 2002), however, in order to activate such effect an individual requires cues

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to action (Glanz, Marcus-Lewis & Rimer, 1997). Using a modified version of the health

belief model, Ali (2002) found that the predictors of CHD prevention tended to be largely

attributable to the knowledge of RFs, which in turn improved the susceptibility and

seriousness of an individual. Hewstone, Fincham and Foster (2005) and Chew et al. (2002)

also found that knowledge about CHD RFs increased an individuals seriousness of the

disease, as well as their susceptibility to the negative unhealthy behaviour consequences; for

example having an MI. Furthermore, Chew et al. (2002) found that as a result of gaining

health information, individuals recognised the benefits of and barriers to practicing HBs.

Additional to the health belief model, several studies have outlined the self-regulatory

model of illness perception and the common-sense model of representation as alternative

approaches (Diefenbach et al. 1996). Both are similar in the assumption that an increased

awareness of health threats leads to representations of preventive behaviour (Petrie &

Wienmann 1997; Hamner & Wilder, 2008). MacInnes (2005) states that an improved

perception of CHD through social messages can consequently, contribute to the development

of five illness cognitions. These include the cause(s), which refers to beliefs about why one

contracts the illness; time-lime, which is the perception about whether the illness is acute or

chronic; identity, which includes the understanding of symptoms; consequence, which refers

to the belief about the outcome of the illness; and cure, which relates to beliefs about how one

recovers (MacInnes, 2005). MacInnes (2005) and Hamner et al. (2008) explain that

increasing ones knowledge of CHD would assume that a health threat is recognised and that

subsequently, an individual will change to a state of health.

Knowledge is therefore, evidently essential as an adjunct to preventative HBs

(MacInnes, 2005). Hamner et al. (2008) found that, after testing 112 women in rural

Alabama, the first and foremost consideration to promote HBs is that the population must be

taught the RFs of CHD. In addition, MacInnes (2005) found that with a limited knowledge

regarding the causes of an MI patients had more negative consequences for how they dealt

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with the illness in terms of making behavioural changes. Furthermore, it is noted by

Kayaniyil et al. (2009) that there was a significant correlation between higher knowledge and

perception of greater negative illness consequences and a greater perception of CHD as a

chronic condition.

2.4. Coronary Heart Disease Knowledge in the General Population

Public awareness and understanding of CHD is essential for both primary and

secondary prevention (Nash, Mosca, Blumenthal, Davidson, Smith & Pasternak, 2003),

however, the general population is shown to only understand some of the main aspects of

CHD (Ayers et al. 2010). Jafray et al. (2005) found that 792 individuals accompanying or

visiting patients across a wide demographic spectrum had a striking lack of knowledge about

CHD, only achieving a median knowledge score of 3 out of a possible maximum of 15. Just

14% were able to correctly describe what they thought CHD meant, 20% were not able to

identify even a single RF and only a minority were able to correctly identify symptoms of

angina (chest pain 36% and dyspnoea 24%) (Jafray et al. 2005). Mochari, Ferris, Adigopula,

Henry and Mosca (2007) also reported that over half of a sample of minorities in New York

(59%) was unaware that CHD was a leading cause of death.

Sanderson et al. (2009) reported that 1,747 adults in the UK were only able to identify

a mean of 2.1 RFs and that a small proportion of the population (9%) did not recognize any

RFs for CHD. But, then again it could be argued that mean scores are not the best indicator to

use. The awareness of the role CHD RFs was also reported by Salamonson et al. (2009) to be

discriminating with most respondents identifying that eating an unhealthy diet and physical

inactivity were RFs for CHD yet, failed to recognise the importance of smoking cessation.

Nash et al. (2003) found that less than half of adults aged 40 years (40.2%) were unaware of

the national guidelines for cholesterol management and that 53.1% either did not know or

overestimated the desirable total cholesterol level for healthy adults. A study about

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consumers understanding of salt, additionally found that 188 female respondents from

Scotland were significantly (p

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score attained the greater the consumption of vegetables (p

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had inadequate physical activity levels. In addition, Khan et al. (2006) reported that only

4.3% of patients with an acute MI in Pakistan exercised at all.

Evidence that knowledge benefits HB can be shown in Salamonson et al. (2007) who

found that there was a significant overall improvement in behaviour as a result of CR;

increased non-smoking behaviour (p

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This pattern of knowledge may however, be due to relatively more aggressive

advertising campaigns as well as educational programs discouraging the use of saturated fats

and tobacco and a relative dearth of the same for obesity (Khan et al. 2006). Yet, despite the

attention in the media around these topics (Oliver-McNeil & Artinian, 2002) it is evident that

this does not necessarily relate to an increase in CHD knowledge. Current or ex smokers are

shown to be less aware smoking is a RF for CHD than those who have never used tobacco

(Woodward, Bolton-Smith & Tunstall-Pedoe, 1994), which could be apparent since tobacco

users adopt such behaviour because they are unaware of the adverse consequences of their

habit (Khan et al. 2006). But it has also been proposed that tobacco users are simply less

prepared to admit the health implications of what is commonly perceived as an unhealthy

behaviour, at least in regard to their own health (Woodward et al. 1994). This can also be

suggested in relation to diet and physical activity.

Another theory might however, be due to difficulties articulating such knowledge as

the level of patients education is shown to be a predictor of CHD knowledge (Karner et al.

2003; Khan et al. 2006). Karner et al. (2003) found that most patients were not able to

express a deep understanding of their disease despite comprehensive information given to

them and Kayaniyil et al. (2009) also determined that there was a significant correlation

between the patients knowledge score achieved and the patients educational background of

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Caputo, 1995) and similarly, Evanoski (1990) found that, on the whole, educational reading

material was written at a high level. This is particularly apparent and problematic when the

patient presents with complicated cardiac disorders; such as ventricular arrhythmias or heart

failure, as a result of CHD (Evanoski, 1990).

2.6. Coronary Heart Disease Knowledge in Healthcare Professionals

Healthcare professionals play an important role in the management of CHD through

health promotion/education in CR (Gray, Bowman & Thompson, 1997) and via more

influential roles in the primary care of risk factor modification (Thompson & Stewart, 2002).

Extensive research into health professionals has broadly reported satisfactory levels of CHD

knowledge (Moore & Adamson, 2001). Moore et al. (2001) determined that most staff (65%),

in a primary care setting, are clear on the dietary recommendations for the general

population; reduction in total dietary fat and an increase in fruit and vegetables, and nurses

are also in general found to be cognisant in CHD RFs (Barnett, Norton, Busam, Boyd, Maron

& Slovis, 2000) and of the message they typically give patients (Jaarsma et al. 2004).

As a result, it has been noted that cardiac nurses (n=130) from a range of European

countries, were found to have adopted a healthier lifestyle than the general population

(UNITE, 2002). However, there is the assumption that these cardiac nurses, who were

attending a scientific meeting in Glasgow, would be more likely to participate in the study

than those nurses with a worse RF profile and thus may not be entirely representative of

cardiac nurses in general (Jaarsma et al. 2004). Jaarsma et al. (2004) has reported that a small

percentage of 112 nurses do, actually, have unhealthy lifestyle behaviours with 11% of nurses

reporting they were current smokers, 27% stating they had a body mass index >25 kg/m 2

(overweight) and over a quarter (27%) stating they did not regularly participate in exercise. In

addition, Hodgetts, Broers and Godwin (2004) found that of 273 physicians working in

Eastern Europe 45% were current smokers and Tucker, Harris and Pipe (2007) demonstrated

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that less than one third of nurses reported to engage in moderate physical activity of 30

minutes/day and 85% stated they ate fast food or snacks one to three times a week.

This suboptimal HB could be attributable to the fact that there are however,

substantial CHD knowledge gaps in health professionals (Moore et al. 2001). Moore et al.

(2001) found that in relation to nutritional knowledge the area of lipid lowering diets and

dietary fats were where a significant amount of confusion existed in healthcare professionals,

as over half of the 109 staff surveyed stated that egg consumption should be restricted to no

more than two per week; a recommendation that can no longer be justified (Department of

Health [DOH], 2004). In addition, Lin et al. (2008) found that nurses had poor understanding

of the disease process and physiology of CHD and furthermore, Heidrich, Behrens, Raspe

and Keil (2005) found that nearly one third of 1,023 physicians working in Germany were

unaware of secondary prevention guidelines.

Standards for health-enhancing behaviours are widely published in various guidelines

and are a useful tool for healthcare professionals to bridge the gap between evidence based

research and clinical medicine (Heidrich et al. 2005). However, even when sufficient

guideline knowledge exists in physicians a substantial amount stated they would only start

RF treatment at levels well above those recommended in current guidelines. For instance,

only a quarter of physicians (24.4%) reported to start comprehensive weight counselling at a

body mass index of 25 to 29.9 kg/m 2 (overweight) and just over half (63.7%) of physicians at

a body mass index of 30 mg/m2

(obese) (Heidrich et al. 2005). Additionally, Heidrich et al.

(2005) found that only 48.6% reported making use of smoking cessation, and it has been

reported that between 1992 and 2000 diet and physical activity counselling took place in

fewer than 45% and 30%, respectively, of primary care visits by adults with CHD RFs (Ma,

Urizar, Alehegn & Stafford, 2005). Thus, physicians fail to provide effective behaviour

change counselling to their patients even when they are aware that CHD risk exists (Ma et al.

2005).

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There are also suggestions that regardless of the knowledge, it is actually beliefs and

misconceptions about living with CHD held by healthcare professions that that influence

behaviour change outcomes (Lin et al. 2008). Newens, McColl, Lewin and Bond (1996)

found that cardiac-related symptoms and cardiac conceptions were significantly inaccurate in

nurses. Lin et al. (2008) additionally, detail that this lack of knowledge and misconception

may not only cause nurses to adopt unhealthy behaviours but can cause patients to have

unnecessarily frightening images of living with CHD. Consequently, patients adopt

profoundly sedentary and avoidant lifestyles which would increase their risk of future cardiac

events (Cooper, Jackson, Weinman & Horne, 2005; Byrne et al. 2005).

Regardless of CHD knowledge, there is also the challenge of effectively delivering

health information which is compounded by the poor communication skills of physicians

(Safeer et al. 2006). Safeer et al. (2006) detail that it is not uncommon for patients to have

difficultly understanding the information given to them by their physicians, as they feel they

are using medical terminology (Bourhis, Roth & McQueen, 1989). Mayeaux, Murphy,

Arnold, Davis, Jackson and Sentall (1996) details that generally, the medical terms used by

physicians in America are not very well understood by patients and Ong, de Haes, Hoos and

Lammes (1995) states that this results in patients not being able to recall half of the

information given to them during consultation. Ni, Nauman, Burgess, Wise, Crispell and

Hershberger (1999) also reported that, even when patients received information from their

healthcare provider about how to take care of themselves, only about half knew some or

little or nothing about their condition (48% and 38%, respectively) and just 14% knew a

lot. There is therefore, a clear chasm between patient receiving information and patients

understanding the content (Safeer et al. 2006). In contrast, however, Moore et al. (2001)

found that 90% of patients in England felt the advice they had been given was understood and

they knew what was expected from them to make the changes that were suggested to them.

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2.7. Coronary Heart Disease Knowledge in Students

The major RFs leading to CHD have their roots in childhood and adolescence

(Manios, Moschandrea, Hatzis & Kafatos, 2002). With this in mind, several primary

initiatives have been put in place to improve CHD awareness through schools and have

resulted positively (Manios et al. 2002). Koutoubi et al. (2005) found that out of 300 college

students 98.3% were knowledgeable about the RFs for CHD correctly identifying high BP,

high blood cholesterol, smoking, obesity and physical inactivity. Felimban (1993) and Bayat,

Pillay and Cassimjee (1998) also found that 99.7% and 49%, respectively, of students were

aware of the adverse effect of smoking and that smoking was associated with CHD. This is

suggested a result of the widespread publicity or the emphasis placed on curriculum design

(Taha et al. 2004).

Conversely, there is also evidence to show that the knowledge of modifiable CHD

RFs can be very low (Lynch et al. 2006). Lynch et al. (2006) reported that as little as 20% of

students in the US were able to recognise high BP, overweight and lack of exercise as RFs

and that as few as 17% were able to identify high blood cholesterol. In addition, Taha et al.

(2004) determined that in Al-Khobar students knowledge on hypertension, diabetes mellitus

and obesity as RFs was rather inadequate and Manios et al. (2002) reported that health,

nutrition and physical activity awareness was limited in primary schools of Crete.

The lack of knowledge however, could be suggested attributable to the educators, as

the overall effect on students HB can be particularly influential (Koutoubi et al. 2005).

Although teachers are shown to have a significantly better knowledge about CHD risk than

their students the knowledge is still unsatisfactory (Taha et al. 2004). Only around 19%

teachers in Saudi Arabia were able to identify diabetes mellitus as a RF, less than half

(42.4%) were able to recognise lack of physical activity as a RF and 39.4% of teachers were

able to identify hypertension as risk for CHD (Taha et al. 2004). Furthermore, Maziak,

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Mzayek and Al-Moushareff (2000) determined that less than 10% of teachers in the north of

Syrian Arab Republic recognized smoking as a health hazard for CHD.

Moreover, a parents level of CHD knowledge is important determinants for HB

(Rasanen, Niinikoski, Keskinen, Helenius, Talvia, Ronemaa et al. 2003). Rasanen et al.

(2003) determined that 45.7% of parents in Finland had only a moderate nutritional

knowledge and that just over half of parents (57.1%) knew the causal relationship between

CHD and diet, and consequently affected the nutritional intake of the children. On the other

hand, it was determined by Taha et al. (2004) that in actual fact the main source of health

knowledge for students, was television (58% males and 61% females) and that parents and

teachers were less of an influence.

Determining the knowledge of adult students (university students) who are less

influenced by teachers or parents shows a high knowledge of CHD RFs (Belardinelli,

Georgiou, Cianci & Purcano, 1999). Almas, Hameed and Tipoo-Sultan (2008) found that

adult students from University graded smoking as the top most RF for CHD (84.5%) and that

they correctly identified hypertension (89%), high blood cholesterol (91.5%), a sedentary

lifestyle (63), obesity (72%), and diabetes mellitus (63%) as modifiable RF. Using a CHD

awareness questionnaire Almas et al. (2008) also found that the mean knowledge score of

adult students was 11.5 out of a maximum 16 (71%). On the other hand, it has been found

that adult students have less knowledge in relation to the treatments of CHD than patients;

such as angiography, as less than half were able to correctly define the procedure and almost

16% had never heard of it (Almas et al. 2008). Yet, it could be suggested that in adult

students who require only primary prevention, knowledge of treatments for established CHD

is not as essential as the knowledge of CHD RFs.

University students often represents the first time many young adults assume

responsibility for their HBs (Koutoubi et al. 2005) and given the increased awareness of CHD

it could be assumed that better HBs are practiced. However, there seems to be evidence

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which suggests that students of this age do not adopt positive HBs. Pan, Dixon, Himburg and

Huffman (1999) state, largely attributable to financial and time constraints, students skip

meal-times and tend to consume large amounts of salty, sweet and high fat foods, as well as

consuming less dietary fibre and vegetables (Pan et al. 1999). Brevard and Ricketts (1996)

also found that University students took in higher amounts of total fat, and saturated fat than

the recommended levels and Wiley, James and Fordan-Belver (1996) determined that

students diets are low in fruit and vegetables.

Students are also less likely to engage in physical activity, with only 14% reporting

participating in at least 60 minutes of moderate to vigorous activity each day (Scully, Dixon,

White & Beckmann, 2007). The participation in the recommended three to five sessions a

week (ACSM, 2006) is also overseen by students as Haase, Steptoe, Sallis and Wardle (2004)

found that University students from 23 countries (North-Western Europe and the US) were

significantly participating in low frequency activity (p=0.001) as well as significantly more

being inactive (p=0.001). Additionally, it has been noted in the UK the freedom of being

away from home combined with lots of socialising and the ability of cheap drinks does mean

many students drink heavily (Gill, 2002), yet for medical students in the US, general alcohol

consumption is found non-excessive with most drinking one (53%) or two drinks per day

(37%) (Frank, Elon, Naimi & Brewer, 2008). Furthermore, it is suggested that students are

the most vulnerable group to begin smoking (Safeer et al. 2006).

2.8. Age-related Differences in Coronary Heart Disease Knowledge

Age appears to have a positive linear relationship with knowledge (Jafray et al. 2005).

Mosca et al. (2000) determined that younger women (25 to 34 years) were less likely to

respond that they did know CHD was the leading cause of death compared with women aged

45 to 64 years, and mean knowledge scores have also shown to significantly (p=0.03)

increase from the 30 year age group to the >60 year age group (Jafray et al. 2005). In

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identified a sedentary lifestyle as a major risk for CHD compared to younger women

(p=0.05). In addition, Sanderson et al. (2009) found that adults in the UK aged over 60 years

significantly identified fewer lifestyle RFs for CHD than those younger (p=0.001). Jafray et

al. (2005) suggests this occurs as a result of current school education initiatives which have

developed over time to spend substantially more time on health education. As a consequence

individuals that attend school nowadays are more knowledgeable than the elderly who may

not have received such instruction during their schooling years (Jafray et al. 2005).

2.9. Gender Differences in Coronary Heart Disease Knowledge

CHD has been socially constructed as a gender-specific disease (MacInnes, 2005)

with the misconception is that CHD is a mans disease (Lockyer, 2002). However, recent

evidence highlights that CHD prevalence is significantly higher in women compared to men

(Hamner et al. 2008). In fact, in the US CHD kills one woman a minute, causing more deaths

in women than the next six causes of death combined (Hamner et al. 2008).

These misconceptions of CHD however, seem to occur predominantly in the women

themselves as they typically underestimate their personal CHD risk (Hart, 2005). Thanavaro

et al. (2006) determined that women had a low CHD knowledge and Mosca et al. (2000)

Oliver-McNeil et al. (2002) found that women across the US only a minority were able to

name the major RFs for CHD; smoking (3%), obesity (9%) and high blood cholesterol (12%).

Furthermore, Crouch et al. (2010) found that women situated in rural Australia were nearly

completely unaware of the risk of CHD and that CHD was the leading cause of death. This is

particularly problematic as non-metropolitan areas of Australia have a significantly higher

(up to 70%) mortality rate from CHD than the metropolitan areas (Australian Institute of

Health and Welfare, 2007).

Women limited in their awareness of their personal risk are consequently not prepared

to deal with health promoting practices (Oliver-McNeil et al. 2002; Thanavaro et al. 2006).

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Oliver-McNeil et al. (2002) found that women with CHD did not practice HBs and it is also

reported that 85% of the women with known CHD did not make lifestyle changes in response

to their diagnosis (Marcuccio, Loving, Bennett & Hayes, 2003). Similarly, Thanavaro et al.

(2006) found that HBs were not performed by women on a regular basis which was

additionally seen to be significantly correlated with CHD knowledge (p=0.01). Conversely, it

has been established that even with a greater knowledge of CHD and personal RFs, this not

an indication that the women will engage in HBs (Oliver-McNeil et al. 2002).

The fact that women do not practice a healthy lifestyle is suggested attributable to the

fact that women have a lack of concern about CHD (Thanavaro et al. 2006). Legato, Padus

and Slaughter (1999) reported that 44% of women surveyed in the US believed that it was

somewhat or very unlikely that they would suffer a heart attack, and 58% believed they were

as likely as or even more likely to die of breast cancer than CHD. Similarly, Mosca et al.

(2000) found that only 9% of women said that the condition they most feared was CHD, in

contrast to 61% of these women who reported that they most feared breast cancer. Thus,

many women underestimate the importance of CHD risk (Crouch et al. 2010).

Mosca et al (2000) also determined that the heightened awareness of breast cancer

reflects the possibility that women feel uniquely related to the disease and that the plethora of

information for breast cancer is targeted at women. Breast cancer awareness is also highly

visible in the community, being the topic of television dramas and documentaries (Crouch et

al. 2010). In contrast however, womens magazines have many columns devoted to losing

weight, exercise and reducing fat intake but these are never presented in terms of preventing

CHD (or other conditions) and packaged with a focus on glamour and slimness (Crouch et al.

2010).

Evidence to suggest differences in CHD knowledge between males and females can

be apparent across all populations. Jafray et al. (2005) reported that in a population of

individuals visiting patients in a Pakistan hospital, females had significantly (p=0.01) more

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CHD awareness compared to males. In addition, Koutoubi et al. (2005) reported that female

students from the US were significantly more likely than males to correctly answer that

lowering blood cholesterol can help those who have already had an MI and that significant

more females were able to identify that high blood cholesterol was related to CHD (p=0.00).

On the other, it has also been found that there are no significant differences in the amount of

CHD RFs identified by male and female adults in the UK (p=0.21) (Sanderson et al. 2009).

The HB of males and females can also be seen to differ significantly with student

males being more likely to consume fast foods (p=0.00), but also more likely to consume at

least four serves of fruit and vegetables (p=0.00), and more likely to meet the physical

activity recommendation (p

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2. Student nurses will be practicing positive HBs.

3. There will be a positive relationship between CHD knowledge and positive HB in

student nurses.

4. There will be evidence of age-related differences in CHD knowledge and HB in

student nurses.

5. There will be evidence of gender differences in the CHD knowledge and HB of

student nurses.

2.11.2. Null Hypothesis

1. Student nurses will not have sufficient CHD knowledge.

2. Student nurses will not be practicing HBs.

3. There will be no relationship between CHD knowledge and HB in student nurses.

4. There will be no age-related differences for CHD knowledge and HB in student

nurses.

5. There will be no gender differences in the CHD knowledge and HB in student nurses.

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Chapter Three:

Methods

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3.1. Introduction to Methods

The purpose of this methods chapter is to communicate and rationalise the methods of

the present study. This includes considering the participants from whom CHD knowledge and

HB information was collected from, the kind of data collection tool that was used to collect

CHD knowledge and HB, the way in which CHD knowledge and HB was collected and how

CHD knowledge and HB was statistically analysed.

3.2. Participants

The sample comprised of third year student nurses attending University. The

exclusion of student nurses in their first or second year of study was based on the

understanding that CHD knowledge is provided as a module to student nurses during their

second year (Informal communication with representative from University, April 2010). The

knowledge of the third year student nurses was therefore, seen to be similar providing a

comparable baseline for association with HB as well as also reassuring the completion of the

study. It was also determined by further informal communication with representatives of

University staff (April, 2010) that CHD knowledge should be similar in third year students

regardless of the institute of study. Universities must abide by current national curriculum

programmes in accordance with the DOH and thus Nursing studies are fairly consistent

throughout different Universities (Informal communication with representative from

University, April 2010).

Given the vast range of institutions from which student nurses could be obtained from

it was determined that the studys sample population would be selected only from

Universities in the north of England. The inclusion of universities situated in this region was

based on statistics from the BHF (2008) which states CHD death rates are significantly higher

in the north of England compared to the rest of the country. The students would therefore,

have a similar risk for CHD being located in this area for at least three years whilst at

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Figure 3 The North ofEngland

University. In addition, as student nurses tend to obtain their first qualified nursing job within

the same area as they have studied (Informal communication from representative of

University, April 2010) student nurses in the north of England would also be potential

advocates for coronary care in a patient population with an increased risk of CHD.

The north of England comprises of 9 counties

as illustrated in figure 3, and a University subject

search (www.ucas.ac.uk), determined that 18

Universities in this region offered at least one type of

Nursing study. These 18 Universities were

subsequently approached, initially via telephone;

where an appropriate contact name and email address

was acquired, and then by email; to secure permission

from the University to include their third year student nurses as well as their cooperation to

send out and distribute the data collection tool on the studies behalf (See Appendix 1 for

Specimen Email). Five of the 18 Universities in the north of England confirmed consent; the

University of Bradford, University of Huddersfield, University of Liverpool, Manchester

Metropolitan University, and Northumbria University (See Appendix 2a, 2b, 2c, 2d, and 2e

for Confirmation Emails), and collectively approximated a potential study sample size of 696

third year student nurses (See Appendix 3 for Sample Size Summary).

3.3. Data Collection Tool

Following a review of the methodological traditions available to use for data

collection and the methods of data collection used in similar research studies it was

determined that the present studies data collection tool was a questionnaire (See Appendix 4

for Review of Methodology). The questionnaire; a Coronary Heart Disease Knowledge and

Health Behaviour questionnaire (CHDKHBQ), consisted of 30 questions split into three

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sections; personal details (4 questions), CHD knowledge (16 questions) and HB (10

questions) (See Appendix 5 for Questionnaire) and, following a pilot study, was shown to

take no more than 12 minutes to complete.

Personal details of the CHDKHBQ establishes the third year student nurses institute

of study (University name), age, gender and the type of Nursing currently being studied.

Since there is no robust knowledge questionnaire validated for non-patient populations

(Kayaniyil et al. 2009), the CHDKHBQ attained CHD knowledge using a combination of

items from two existing validated questionnaires and four investigator generated questions to

include areas of CHD knowledge which the other two sources failed to contain; fruit and

vegetables, oily fish, alcohol and salt. The validated questionnaires were the modified CHD

Knowledge questionnaire used by Oliver-McNeil et al. (2002) and the Coronary Awareness

and Knowledge questionnaire derived from Kayaniyil et al. (2009). All CHD knowledge

questions were formatted as multiple-choice with either four answers or true or false options.

The HB questions of the CHDKHBQ were investigator generated and were formatted as

either multiple-choice options or yes or no answers. These generated questions related to the

existing knowledge questions, for example What is the recommended daily amount of fruit

and vegetables? was rephrased to ask How many portions of fruit and vegetables do you eat

a day?. Appendix 6 provides the justification behind the questions selected for both the CHD

knowledge and HB sections of the CHDKHBQ.

The scoring of the CHDKHBQ was divided into two sections; knowledge and HB.

Knowledge questions consisted of one correct answer so knowledge scores ranged from 0 to

16 while HB scoring used a ranking system that established a better behaviour gaining a

higher score. Consequently HB scores ranged from 10 to 29 (See Appendix 7 for

Questionnaire Scoring Sheet). The grouping of the scores for each section followed a similar

method to Thanavaro et al. (2006) where cut-off percentages determined categories. Good

knowledge was achieved by a score 80% of the total, average knowledge achieved by a

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score 40% but

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University of Chester (See Appendix 8 for Confirmation Letter), a researcher generated email

(See Appendix 9 for Specimen Email) was sent to the five Universities that agreed to take

part in the study. This email was intended for the third year student nurses of that University,

detailing the nature of the study and invited them to take part. Once forwarded on by the

University staff member the third year student nurse had the opportunity to click on a link

which would allow them to complete the CHDKHBQ online through a survey administrator;

Survey Monkey (See Appendix 10 for Specimen of Questionnaire in Survey Monkey).

The email also included an attached participant information sheet which gave further

information about why the research was being undertaken and highlighted the third year

student nurses voluntary participation, confidentiality of results and provided researcher

contact information (See Appendix 11 for Participant Information Sheet). Two out of the five

Universities required a follow up email when it was recognised that no third year student

nurses from that institute had completed the CHDKHBQ online a month following the initial

email (See Appendix 12 for Specimen of Follow-up Email).

3.5. Data Analysis

All data was analysed using the Statistical Package for Social Sciences [SPSS] for

Windows version 17.0 (2009) and significance was set at the 0.05 level.

The CHD knowledge of the third year student nurses (hypothesis 1) was determined

using descriptive statistics which was then related to one of the scoring categories; good,

average or poor. As detailed in Table 2, good CHD knowledge was categorised as a score

higher than 13, average CHD knowledge by a score between 6 and 12 and poor CHD

knowledge by a score less than 5. To establish the responses provided by the third year

student nurses (correct/incorrect) differed significantly chi-squares analysis were used.

To determine the HB of the third year student nurses (hypothesis 2) the overall HB

was also analysed using descriptive statistics and like with CHD knowledge related to one of

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the three scoring categories. Good HB was classified by a score over 25, average by a score

of 18 to 23 and poor by a generated score less that 18 (see table 2). HB was additionally then

analysed using chi-squares analysis to verify that the responses provided by the third year

student nurses were significantly different.

To analyse the relationship between CHD knowledge and HB in student nurses

(hypothesis 3), a Spearmans Rho correlation was conducted since the data for CHD

knowledge failed to assume a normal distribution (Shapiro Wilk) (see Appendix 13 for SPSS

output). For further analysis, cross tabulations were also performed in relation to the three

lifestyle RFs; smoking, physical activity/exercise and diet and weight management, to

determine any significant associations between the knowledge and behaviour of the third year

student nurses.

In order to determine any age-related and gender differences in CHD knowledge and

HB (hypotheses 4 and 5) the data was analysed in relation to a normal distribution (Shapiro

Wilk) and a normal variance (Levenes Test) by category. Normal distributions were met

with regards to age and CHD knowledge, gender and CHD knowledge, and gender and HB,

but not for age and HB, while normal variances were met for all (see Appendix 13 for SPSS

output also). Consequently, separate Independent T-Test were performed for the analysis of

differences between age and CHD knowledge, gender and CHD knowledge and gender and

HB whilst the non-parametric equivalent; a Mann Whitney U Test, was performed on age and

HB. Cross tabulations were then additionally conducted to establish differences within the

responses provided by the third year student nurses, and chi-squares analysis verified these

were significant. With regards to the analysis of age-related and gender differences, age was

categorised as those straight from school education (ages 18 to 22) and mature students

(ages 23), and gender was categorised as males and females.

Additionally to the analysis of the studies hypotheses, the questions of the

CHDKHBQ were also analysed using descriptive statistics, to establish any specific area of

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lack of knowledge or poor HB within the third year student nurses. This would be

influential evidence for development needs in curriculum design or awareness of CHD.

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Chapter Four:

Results

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University of Bradford

University of Huddersfield

University of Liverpool

Manchester Metropolitan UniversityNorthumbria University

4.1. Introduction to Results

The purpose of this results section is to determine the demographics of the third year

student nurses that took part in the study and to identify the outcomes of CHD knowledge and

HB in relation to the studies aims and hypotheses. This entails detailing the overall CHD

knowledge and HB of the third year student nurses, whether there is evidence of an

association between CHD knowledge and HB in third year student nurses and if any age-

related or gender differences in the CHD knowledge and HB of the third year student nurses

occurred.

4.2. Demographics

Fifty four out of a potential 696 third year student nurses voluntarily took part in the

study and completed the CHDKHBQ online. This equates to an 8% response rate. The

distribution of the third year student nurses varied, although not significantly (p=0.12),

among the five institutes of study. There were nine third year student nurses from the

University of Bradford (17%), 18 from the University of Huddersfield (33%), seven from the

University of Liverpool (13%), 12 from Manchester Metropolitan University (22%) and eight

from Northumbria University (15%). This distribution is illustrated in figure 5.

Figure 5 Distribution of Student Nurses between the Five Different Universities

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Male Female

The mean age of the responding third year student nurses was 26 5 years. Notably

more responding student nurses were classified as mature students (n=33, 61%) compared

to those straight from school education (n=21, 39%), as demonstrated in figure 6. However,

this characteristic was found to be not significantly different within the sample of student

nurses (p=0.10).

Figure 6 The Student Nurses by Age

The gender of the responding third year student nurses on the other hand, was

determined significantly different (p=0.00), as a substantially larger proportion of females

(n=47, 87%) compared to males (n=7, 13%) took part in the study. Figure 7 illustrates this.

Figure 7 The Student Nurses by Gender

The branch of nursing that was being studied by the third year student nurses was

additionally found to be significantly different (p=0.00). Figure 8 demonstrates that the

responding third year student nurses were mainly studying Adult Nursing (n=40, 74%) with

Mature Students Straight from Education

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05

10152025303540

45

Adult Nursing Child Nursing Mental Health Nursing

LearningDisability Nursing

Other

Branch of Nursing

N o . o

f S t u d e n

t s

very few studying Child Nursing (n=7, 13%) or Mental Health Nursing (n=7, 13%), and

no third year student nurses studying Learning Disability Nursing or Other.

Figure 8 The Branch of Nursing Studied by the Student Nurses

4.3. Coronary Heart Disease Knowledge

The CHD knowledge of the responding third year student nurses was classified as

good with a mean score of 13 2. Table 3 demonstrates that the majority (15/16) of the CHD

knowledge questions were answered correctly by the third year student nurses except for

question 13, where a larger proportion of the student nurses (n=42, 78%) answered

incorrectly. There is also evidence that two of the CHD knowledge questions, question 12

and question 17 were answered correctly by all of the third year student nurses (n=54, 100%)

(See table 3 also).

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Table 3 Summary of Coronary Heart Disease Knowledge Questions

QuestionsCorrect

n (%)

Incorrect

n (%)

Sig.

p value

Q5. What is coronary heart disease? 39 (72) 15 (28) 0.00*

Q6. A risk factor of coronary heart disease that you

cannot change is?50 (93) 4 (7) 0.00*

Q7. The single most preventable cause of death

and disease in the United States is?45 (83) 9 (17) 0.00*

Q8. Which of the following blood fats is thought to

lower the risk of coronary heart disease?36 (67) 18 (33) 0.01*

Q9. Which of the following is a direct benefit of

exercise?42 (78) 12 (22) 0.00*

Q10. The best type of physical activity to maintain

cardiovascular fitness isexercise?50 (93) 4 (7) 0.00*

Q11. Most people could benefit from diets? 34 (63) 20 (37) 0.06

Q12. What is the recommended daily amount of

fruit and vegetables?54 (100) 0 (0) 0.00*

Q13. Women who persistently drink more than

units of alcohol a day and men who drink more

than are more likely to suffer from the riskfactors associated with coronary heart disease?

12 (22) 42 (78) 0.00*

Q14. The average daily intake of salt by adults in

the United Kingdom is 9g, is this?48 (89) 6 (11) 0.00*

Q15. People who are physically active on a regular

basis can cut their risk of heart disease in half?46 (85) 8 (15) 0.00*

Q16. Small changes in what you eat can lower

blood cholesterol?52 (96) 2 (4) 0.00*

Q17. A person can reduce their chances of dyingfrom heart disease through lifestyle changes?

54 (100) 0 (0) 0.00*

Q18. It does not help to quit smoking after many

years because ones health is already damaged?51 (94) 3 (6) 0.00*

Q19. To get cardiac benefit from exercise, you

need to get sweaty and out of breath?41 (76) 13 (24) 0.00*

Q20. Eating fish rich in Omega 3 can improve

your chances of not developing coronary heart

disease?

33 (61) 21 (39) 0.10

*significant difference (

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0

5

10

15

20

25

30

35

40

Yes No

Do you currently smoke?

N o .

o f S t u d e n

t

Table 3 also demonstrates that the responses provided by the third year student nurses

for the CHD knowledge questions were generally (14/16) seen to differ significantly

(p

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10

15

20

25

30

35

40

Yes No

Do you add salt to your food at the tabl e?

N o .

o f S t u d e n

t

0

5

10

15

20

25

None 1 to 2 3 to 5 5 to 7

How many times a week do you participate in 30 minutes ofexercise?

N o .

o f S t u d e n

t

Figure 10 Physical Activity/Exercise Behaviour of the Student Nurses*significant difference

In relation to the salt intake of the third year student nurses it was found to be not

significantly different; whether the student nurses did or did not add salt to their food both

during cooking and at the table (p=0.59 and p=0.41, respectively). Figure 11 demonstrates

that almost equal responses provided by the third year student nurses about adding salt to

food when cooking (yes n=25 and no n=29) and whilst at the table (yes n=24 and no n=30).

Figure 11 Salt Intake of the Student Nurses

There was also no significant difference in the third year students weekly fish

consumption (p=0.79) and daily fruit and vegetable intake (p=0.29). Figure 12 demonstrates

that almost equal numbers of student nurses did (n=28) and did not (n=26) consume one

portion of oily fish per week, and figure 13 details that a larger proportion of student nurses

* *

10

15

20

25

30

35

40

Yes No

Do you add salt to your food when cooking?

N o .

o f S t u d e n

t

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10

14

18

22

26

30

No Yes

Do you eat more than portion of oily fish per week?

N o .

o f S t u d e n

t

ate one to two portions of fruit and vegetables a day (n=26, 48%), with a small proportion

consuming three to four portions a day (n=18, 33%) and five a day (n=10, 19%), and no

student nurses consuming more than five a day.

Figure 12 Weekly Fish Consumption of the Student Nurses

Figure 13 Daily Fruit and Vegetable Intake of the Student Nurses

Figure 14 illustrates that significantly (p=0.00) more third year student nurses (n=36)

reported consuming one unit of alcohol per day (67%), 13 reported consuming two units per

day (24%), only five consuming three units per day (9%) and no student nurses responded

that they consumed equal to or more than the alcohol limit for CHD development (four units

per day).

0

5

10

15

20

25

30

1 to 2 3 to 4 5 +5

How many portions of fruit and vegetables do you eat aday?

N o .

o f S t u d e n

t

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0

5

10

15

20

25

30

35

40

Butter Low Fat/CholesterolLowering/None

What type of spread do you usually use on you bread?

N o .

o f S t u d e n

t

0

5

10

15

20

25

30

35

40

1 2 3 4 +4

How many units of alcohol do you consume in one day?

N o

. o

f S t u d e n

t

Figure 14 Alcohol Consumption of the Student Nurses*significant difference

Figure 15 and 16 shows that the third year student nurses were also predominantly

using the healthier low fat or cholesterol lowering spreads (70%) and either

vegetable/sunflower oil or olive oil (54% and 46%, respectively). However, these generated

responses were only significantly different in relation to the spread used (p=0.00) and not oil

used (p=0.59). The significance generated for oil used nonetheless, was evidently between

the use of vegetable/sunflower oil and olive oil as no student nurse responded to using lard or

dripping (See figure 16).

Figure 15 Spread Use of the Student Nurses*significant difference

*

*

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Figure 16 Oil Use of the Student Nurses

Crisps (n=25), fruit (n=23) and chocolate (n=25) were evidently viewed as the main

selected snack choice by the third year student nurses and two student nurses reported that

they did not snack in-between meals. Furthermore, when a overall snack score was calculated

for the usual in-between meal snack consumption of the third year student nurses (using the

score of one for crisps, chocolate, biscuits, sweets, and cake, a score of two for yoghurt,

and a score of three for fruit and none), significantly more generated a medium snack

score (p=0.01), which can be demonstrated in figure 17.

Figure 17 Snack Score for the In-between Meal Snacks Consumed by the Student

Nurses *significant difference

0

5

1015

20

25

30

35

Lard/Dripping Vegetable/Sunflower Olive

What type of fat or oil would you usually use for cooking?

N o . o

f S t u d e n

t

0

2

4

68

10

12

14

16

1 2 3 4 5 6 7 8

Snack Score

N o . o

f S t u d e n

t s

*

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answers were generated by non-smoking student nurses, all the incorrect answers were

generated by third year student nurses who were smokers (See table 4 also).

Table 4 Smoking Knowledge vs. Smoking Behaviour

Question ResponseDo you currently smoke? Sig.

p valueYes No

Q6. A risk factor of coronary heart

disease that you cannot change is?

Correct 16 340.18

Incorrect 0 4

Q7. The single most preventable cause of

death and disease in the United States is?

Correct 15 300.18

Incorrect 1 8

Q18. It does not help to quit smoking

after many years because ones health is

already damaged?

Correct 13 380.01*

Incorrect 3 0

*significant difference

4.5.2. Physical Activity/Exercise

The third year student nurses physical activity/exercise participation and knowledge

of physical activity/exercise was found to be non-significantly associated, determined

through the use of question 9 (p=0.79), question 10 (p=0.40), question 15 (p=0.82), and

question 19 (p=0.19) from the CHDKHBQ. Table 5 demonstrates that although the majority

of third year students that correctly answered the four physical activity/exercise related

questions were participating in either none or, one or two sessions a week most of the student

nurses, if not all, that did exercise more often; three to five and five to seven session a week,

were also more knowledgeable in relation to the four physical activity/exercise questions.

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Table 5 Physical Activity/Exercise Knowledge vs. Physical Activity/Exercise

Behaviour

Question Response

How many times a weeks do

you participate in 30

minutes of exercise?

Sig.

p value

None 1-2 3-5 5-7

Q9. Which of the following is a direct

benefit of exercise?

Correct 17 15 7 30.79

Incorrect 3 5 3 1

Q10. The best type of physical activity to

maintain cardiovascular fitness

isexercise?

Correct 19 17 10 40.40

Incorrect 1 3 0 0

Q15. People who are physically active on

a regular basis can cut their risk of heart

disease in half?

Correct 17 17 8 40.82

Incorrect 3 3 2 0

Q19. To get cardiac benefit from

exercise, you need to get sweaty and out

of breath?

Correct 12 17 9 30.19

Incorrect 8 3 1 1

4.5.3. Diet/Weight Management

The third year student nurses dietary intake and knowledge of diet can be

evidently non-significantly associated (p>0.05) by using five separate categories; salt, fish,

fruit and vegetables, alcohol, and fat. Table 6 demonstrates that knowing the average daily

intake of salt by adults (9g) was too much, related to an non significant response to whether

the third year students used salt when cooking (p=0.85) or added salt to food at the table

(p=0.25), and table 7 determines that the perception that eating fish rich in Omega 3 (fatty

acids) can improve your chances of not developing CHD was non-significantly related to the

third year student nurses fish consumption (p=0.54).

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Table 6 Salt Knowledge vs. Salt Intake

Question Response

Do you add salt

to your food

when cooking?

Sig.

p value

Do you add salt to

your food at the

table?

Sig.

p value

Yes No Yes No

Q14. The average daily

intake of salt by adults

in the United Kingdom

is 9g, is this?

Correct 22 26

0.85

20 28

0.25

Incorrect 3 3 4 2

Table 7 Fish Knowledge vs. Fish Consumption

Question Response

Do you eat 1 portion of

oily fish per week?Sig.

p valueYes No

Q20. Eating fish rich in Omega 3 can

improve your chances of not developing

coronary heart disease?

Correct 16 170.54

Incorrect 12 9

While all third year student nurses identified that the recommended daily amount of

fruit and vegetables is five a day, only a small minority (n=10) actually carried out this

behaviour. More student nurses were consuming one to two portions (n=26) or three to four

portions (n=18) of fruit and vegetables a day (See table 8). But, given that the response to

question 12 was constant (100% correct) no statistical significance could be obtained in

relation to the association between fruit and vegetable knowledge and behaviour.

Table 8 Fruit and Vegetable Knowledge vs. Fruit and Vegetable Intake

Question Response

How many portions of fruit and

vegetables do you eat a day?

1-2 3-4 5 +5

Q12. What is the

recommended daily amount

of fruit and vegetables?

Correct 26 18 10 0

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Table 9 illustrates that although the majority of third year student nurses answered

incorrectly to question 13, they also generally were consuming low amounts of alcohol per

day; 1 unit (n=36), 2 units (n=13) and 3 units (n=5). Consequently, the association was found

to be non-significant (p=0.53).

Table 9 Alcohol Knowledge vs. Alcohol Consumption

Question Response

How many units of alcohol

do you consume in one day?Sig.

p value1 2 3 4 +4

Q13. Women who persistently drink

more than units of alcohol a day and

men who drink more than are more

likely to suffer from the risk factors

associated with coronary heart disease?

Correct 8 2 2 0 0

0.53

Incorrect 28 11 3 0 0

While more student nurses chose the healthier options in relation to spread and oil

use, knowing that high density lipoproteins lowered the risk of CHD (question 8) did not

significantly relate to the type of spread used on bread (p=0.40), or the type of oil used for

cooking (p=0.44) (See table 10). Table 10 also shows similarly, that non-significant

associations with spread and oil use where found in response to question 11 (spread p=0.97,

cooking oil p=0.33) and question 16 (spread p=0.52, cooking oil p=0.92).

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Table 10 Fat Knowledge vs. Spread and Oil Use

Question Response

What type of spread do

you usually use on

bread?

Sig.

p value

What type of fat or oil

do you usually use for

cooking?

Sig.

p value

Butter LF/CL/N Lard V/S Olive

Q8. Which of the

following blood fats

is